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Medicare Unmasked — The Continued Campaign to Rein In Medicare Fraud

As part of its ongoing crusade to shine a light on Medicare reimbursement, the Wall Street Journal has uncovered some disturbing details on how certain doctors appear to be gaming the system. This comes from the Journal’s rummaging through the Medicare data the Center for Medicare and Medicaid Services (CMS) released in April — the first time ever — on nearly a million healthcare providers. What the Journal found shows despite the government’s noble efforts to clean up the program, it has a long way to go in even making a dent in the estimated $60 billion annual tab for Medicare fraud and abuse.

Here are the profiles of the four questionable practitioners the Journal was able to dig up.

Ronald Weaver. His internal medicine practice received $2.3 million from Medicare in 2012. Even though he is not a cardiologist, 98% of his Medicare proceeds came from a cardiac procedure (known as “enhanced external counterpulsation”) which is rarely used by heart doctors. In fact, the 141 cardiologists at the renowned Cleveland Clinic collectively used it on only six patients last year. Dr. Weaver, however, apparently used it on virtually every one of his 615 Medicare patients, billing the government for more than 16,000 treatments.

Evangelos Geraniotis. His urology practice received $2.1 million from Medicare in 2012, the most of any other doctor in the specialty. Nearly $1 million of these proceeds came from a rarely used urological procedure (known as “cystoscopy and fulguration”) which he performed 1,757 times in 2012. During the same period, only about 10% of urology practitioners in the data set used this procedure, and they did so on average only 38 times.

Gary Marder. His dermatology practice received $3.7 million from Medicare in 2012. $2.4 million of these proceeds came from a radiation procedure for treating melanoma used by just two other doctors in the data set. He billed for the procedure 15,600 times for work supposedly done on 94 patients. That works out to roughly 166 treatments per patient (or more than three treatments per week for a full year).

James Beale. His orthopedic surgery practice received $3.7 million from Medicare in 2012, more than any other practice in his specialty. Yet, his practice did not perform a single surgery on a Medicare patient. His chief Medicare revenue source — $2.3 million worth — was a type of massage therapy procedure. His practice billed Medicare for it more than 107,000 times (or 150 times per patient). By contrast, the average doctor or physical therapist who billed for this treatment did so only 520 times for less than $11,000.

Altogether, the Wall Street Journal found more than 2,300 healthcare providers earned $500,000 or more from Medicare in 2012 from a single procedure or service, with many of them “operating outside their areas of expertise or deviating from standard medical practice.” The doctor paid the most by Medicare was the high-profile south Florida ophthalmologist Salomen Melgen who, according to the Journal, has been fighting with the government for years over charges of overbilling. He received more than $20 million from Medicare in 2012. That would treat quite a lot of eyeballs for any single medical practice.

With these kinds of dubious billings, it is no wonder that Medicare fraud continues at record levels. No doubt, the government is working hard with some real success at going after healthcare fraud through its “HEAT” (Health Care Fraud Prevention and Enforcement Action Team) taskforce. It recovered more than $4 billion in each of the last two years and is estimated to have returned more than $8 to the US fisc for every dollar spent on combating fraud. See Another Record Breaking Year….But it remains a drop in the bucket of total healthcare fraud this country faces. Maybe with this new transparency over Medicare billing information, and with a little help from its friends — like the Wall Street Journal and a few brave whistleblowers — the government will be able to accomplish even more in its campaign to rein in Medicare fraud.

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If you would like more information or would like to speak to a member of Constantine Cannon’s whistleblower lawyer team, please click here.

One Response to “Medicare Unmasked — The Continued Campaign to Rein In Medicare Fraud”

I have noticed that doctors At Carolinas Medical Center, (PCP plus 2 specialists), have started marking their exams as Comprehensive, ie higher charge to Medicare, when my husband is not even physically examined at all. Are there Medicare guidelines for what constitutes a comprehensive exam? We pay the same copay-but the Medicare billing is maximum. We changed his PCP Dr, and now the cost billed to Medicare is a third of what is was before and the new Dr actually examines my husband!